Radiologic placement of a low profile implantable venous access port in a pediatric population

Outcomes of Pediatric Osteogenesis Imperfecta Patients Requiring Port-a-Cath Placement for Long-Term Vascular Access

Intravenous (iv) bisphosphonates are widely used to treat the skeletal manifestations of osteogenesis imperfecta (OI). Obtaining peripheral iv access in pediatric patients with OI is often difficult and traumatic. Although this may be mitigated with surgically placed iv ports (port-a-caths), surgeons may be hesitant to perform this procedure on these children because of the lack of safety data. This study aims to gain better insight into the safety and efficacy of port-a-cath use in this population and identify risk factors for port-a-cath complications. In the present study, we conducted a retrospective cohort analysis of patient characteristics and the incidence of port-a-cath-related complications in children with OI. Fifty-three port-a-caths were placed in 29 children (21 males and 8 females). Of the 29 patients, most are OI type III (n = 18), followed by type I (n = 4), type IV (n = 4), and type V (n = 3). At the time of initial port-a-cath placement, the median age was 52 months (10-191 months), and the median weight was 7.9 kg (5.1-41.1 kg). Most patients (n = 20) weighed less than 10 kg during initial placement. Weight correlated significantly with OI type (p = 0.048), sex (p = 0.03), and vessel used (p = 0.02). Median initial port-a-cath longevity was 43 months (1-113 months), and we found no significant difference in port-a-cath longevity between sexes, OI types, or vessels used. Most patients (n = 19) required multiple port-a-cath placements. There is a significant difference (p = 0.02) between the number of placements and OI type, with type IV having more than type III. Port-a-cath removal was almost always due to mechanical complications (n = 19) but also for infection (n = 1) and malposition (n = 1). Eight patients still had their initial port-a-caths in place at the conclusion of this study. These findings indicate that complications associated with port-a-cath placement are mild and can be used to safely deliver iv bisphosphonates to pediatric OI patients. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Ultrasound guidance for Port-A-Cath insertion in children; a comparative study

Background

Gaining vascular access in children is challenging. Ultrasound-guided central line insertion in adults became the standard of care; however, its role in children is not clear. Our objective was to evaluate the ultrasound-guided Port-A-Cath or totally implanted long-term venous access device insertion in pediatric patients compared to the traditional approach.

Methods

This single-institution retrospective cohort study included 169 children who had port-A-catheters between May 2016 and Oct 2019. The patients were divided into two groups; group A included patients who had Port-A-Cath insertion using the landmark method (n = 117), and Group B included patients who had ultrasound-guided Port-A-Cath insertion (n = 52). Preoperative, operative, and postoperative data were collected and compared between the two groups. The study outcomes were operative time and catheter insertion-related complications.

Results

There was no significant difference in age or gender between both groups (P = .33 and .71, respectively). Eleven cases in group A and two cases in group B were converted to cut down technique because of difficulty in inserting the guidewire. There was no difference in the indication of the need for the port-A-Cath between both groups. The mean operative time for group A was 47 min and for group B was 41.7 min (P < .042). Two patients had intraoperative bleeding and hemothorax and required blood transfusion and chest tube insertion in group A. No statistically significant difference was found in the reported complications between the groups. However, the insertion-related complications were higher in group A (P = .053). No procedure-related mortality was reported.

Conclusions

Ultrasound-guided insertion of Port-A-Cath is an effective and safe technique with a reduction of failure rate. It should be considered the standard technique for Port-A-Cath insertion in the pediatric population.

Venous Ports in Infants

PURPOSE

To evaluate technical success and the incidences of, and risk factors for, mechanical and infectious complications of venous port placement in infants.

MATERIALS AND METHODS

This was a retrospective single-institution cohort study of port placement in infants (age < 1 y) from January 2006 through June 2016 (mean age, 7.5 mo ± 3.3; mean weight, 8.1 kg ± 1.9). Age, weight, sex, side of placement, tip position, and indication for placement (chemotherapy vs other) were recorded. Total catheter-days (CDs), mechanical complications, and central catheter-associated bloodstream infections (CCABSIs) were identified.

RESULTS

During the study years, 64 ports were placed in 64 infants, with a technical success rate of 100%. The mean catheter life was 321 days (total range, 4-1,917 d; interquartile range [IQR], 107-421 d). There were 13 CCABSI events (0.63 per 1,000 CDs); of these, 8 (12.5% among 64 patients) required port removal for infection. There was an increase in CCABSIs in patients with left-sided port placement (relative risk [RR], 3.22; 95% confidence interval [CI], 1.02-10.14; P = .05). There were 8 mechanical complications of the port reservoir or catheter (0.39 per 1,000 CDs). Of these, 2 (3.1%) required removal. Patients in the lowest weight quartile were at an increased risk of mechanical complications (RR, 4.37; 95% CI, 1.09-17.48; P = .04).

CONCLUSIONS

Venous ports can be placed with a high rate of technical success in infants. Left-sided ports and low weight are associated with increased infectious and mechanical complications, respectively.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

BACKGROUND/PURPOSE

To evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population.

MATERIALS AND METHODS

Ninety-two children (52 boys, 40 girls; mean age, 8.5 years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed.

RESULTS

In total, 102 CVPs were implanted in 92 children with a mean catheter time of 364 days (total, 38,224 days; range, 14-1911 days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred.

CONCLUSION

Image-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Cost and Morbidity Analysis of Chest Port Insertion: Interventional Radiology Suite Versus Operating Room

PURPOSE

To compare complications and cost, from a hospital perspective, of chest port insertions performed in an interventional radiology (IR) suite versus in surgery in an operating room (OR).

METHODS

This study was approved by an institutional review board and is HIPAA compliant. Medical records were retrospectively searched on consecutive chest port placement procedures, in the IR suite and the OR, between October 22, 2010 and February 26, 2013, to determine patients' demographic information and chest port-related complications and/or infections. A total of 478 charts were reviewed (age range: 21-85 years; 309 women, 169 men). Univariate and bivariate analyses were performed to identify risk factors associated with an increased complication rate. Cost data on 149 consecutive Medicare outpatients (100 treated in the IR suite; 49 treated in the OR) who had isolated chest port insertions between March 2012 and February 2013 were obtained for both the operative services and pharmacy. Nonparametric tests for heterogeneity were performed using the Kruskal-Wallis method.

RESULTS

Early complications occurred in 9.2% (22 of 239) of the IR patients versus 13.4% (32 of 239) of the OR patients. Of the 478 implanted chest ports, 9 placed in IR and 18 placed in surgery required early removal. Infections from the ports placed in IR versus the OR were 0.25 versus 0.18 infections per 1000 catheters, respectively. Overall mean costs for chest port insertion were significantly higher in the OR, for both room and pharmacy costs (P < .0001). Overall average cost to place chest ports in an OR setting was almost twice that of placement in the IR suite.

CONCLUSIONS

Hospital costs to place a chest port were significantly lower in the IR suite than in the OR, whereas radiology and surgery patients did not show a significantly different rate of complications and/or infections.

Infectious morbidity by catheter type in neutropenic children with cancer

BACKGROUND

Three central venous catheters types are commonly used in pediatric cancer: totally implantable catheters (ICs; eg, mediports, portacaths), tunneled externalized catheters (eg Broviac® or Hickman® catheters [Bard Medical]) and peripherally inserted central catheters. While previous studies have examined risks for catheter-related infections, this is the first large multicenter study to compare catheter-associated infectious morbidity through patient outcomes and hospital utilization.

METHODS

A historical cohort analysis was conducted using data from the Pediatric Health Information System reporting 1167 hospitalizations of neutropenic patients with childhood cancer and a central venous catheters. Multivariate analyses controlled for age, ethnicity, gender, malignancy category and transplant status. Outcomes included incidence of serious bacterial infection, mortality, duration of hospitalization, time and use of intensive care unit and antibiotic usage.

RESULTS

Neutropenic cancer patients with totally ICs (n = 429) have a statistically significant approximately 50% decrease in length of hospitalization (P < 0.001), risk for requiring an intensive care unit stay (P = 0.002), documented serious bacterial infection (P = 0.001) and days on antibiotics (P < 0.001) when compared with patients with tunneled externalized catheters (n = 463). Similar differences were found comparing hospitalizations of patients with ICs to those with peripherally inserted central catheters (n = 275). No difference in mortality was observed among catheters groups.

CONCLUSIONS

In neutropenic pediatric oncology patients with a central venous catheters, ICs are associated with the least hospital utilization including shortest duration of hospitalization, intensive care unit time and antibiotic therapy when compared with tunneled external catheters and peripherally inserted central catheters. The impact of differences in catheter-associated infectious morbidity on patient outcomes and hospital utilization should be included in clinical decision making.

Clinical outcome after a totally implantable venous access port-related infection in cancer patients: a prospective study and review of the literature

Morbidity and mortality after a totally implantable venous access port (TIVAP)-related infection in oncology patients have rarely been studied. We conducted this study to assess the incidence and factors associated with the following outcome endpoints: severe sepsis or septic shock at presentation, cancellation of antineoplastic chemotherapy, and mortality at week 12. We conducted a prospective single-center observational study including all adult patients with solid cancer who experienced a TIVAP-related infection between February 1, 2009, and October 31, 2010. Patients were prospectively followed for 12 weeks. Among 1728 patients receiving antineoplastic chemotherapy during the inclusion time, 72 had an episode of TIVAP-related infection (4.2%) and were included in the study (median age, 60 yr; range, 28-85 yr). The incidence of complications was 18% for severe sepsis or septic shock (13/72 patients), 30% for definitive cancellation of antineoplastic chemotherapy (14/46 patients who still had active treatment), and 46% for death at week 12 (33/72 patients). Factors associated with severe sepsis or septic shock were an elevated C-reactive protein (CRP) level and an infection caused by Candida species; 4 of the 13 severe episodes (31%) were due to coagulase-negative staphylococci (CoNS). Factors associated with death at week 12 were a low median Karnofsky score, an elevated Charlson comorbidity index, the metastatic evolution of cancer, palliative care, and an elevated CRP level at presentation. Hematogenous complications (that is, infective endocarditis, septic thrombophlebitis, septic pulmonary emboli, spondylodiscitis, septic arthritis, or organ abscesses) were found in 8 patients (11%). In conclusion, patients' overall condition (comorbidities and autonomy) and elevated CRP level were associated with an unfavorable clinical outcome after a TIVAP-related infection. Candida species and CoNS were responsible for severe sepsis or septic shock.

Central venous access ports in children treated for hematopoietic malignancies

During past 10 years 234 central venous access ports (CVAP) were implanted in 225 patients at the Department of Pediatric Hematology and Oncology in Zabrze. Mean exposure time was 745 days and total implantation time reached 173,768 days. Complications were encountered in 17 patients (7.6%). This mainly concerned central venous line infection, which led to removal of 10 CVAP (4.4%). The remaining complications necessitating removal of the CVAP consisted mainly of mechanical problems (catheter fracture, occlusion, and erroneous implantation to artery). In the opinion of the authors, subcutaneously implanted CVAP are a safe and effective option for high-dose chemotherapy deliverance in childhood cancer patients.

Interventional radiology and the care of the pediatric oncology patient

Interventional radiology has become increasingly involved in the diagnosis and management of the pediatric oncology patient. Percutaneous biopsy and needle aspiration can be performed for solid and liquid lesions with image guidance, both for the primary diagnosis and for management of sequelae of cancer therapy. Therapeutic options also can be performed with image guidance, including radiofrequency ablation and transarterial chemoembolization. When surgical resection is required, image guided tumor localization can be used to aid in identifying small lesions.

Pediatric vascular access

Pediatric interventional radiologists are ideally suited to provide vascular access services to children because of inherent safety advantages and higher success from using image-guided techniques. The performance of vascular access procedures has become routine at many adult interventional radiology practices, but this service is not as widely developed at pediatric institutions. Although interventional radiologists at some children's hospitals offer full-service vascular access, there is little or none at others. Developing and maintaining a pediatric vascular access service is a challenge. Interventionalists skilled in performing such procedures are limited at pediatric institutions, and institutional support from clerical staff, nursing staff, and technologists might not be sufficiently available to fulfill the needs of such a service. There must also be a strong commitment by all members of the team to support such a demanding service. There is a slippery slope of expected services that becomes steeper and steeper as the vascular access service grows. This review is intended primarily as general education for pediatric radiologists learning vascular access techniques. Additionally, the pediatric or adult interventional radiologist seeking to expand services might find helpful tips. The article also provides education for the diagnostic radiologist who routinely interprets radiographs containing vascular access devices.

Lymphatic Leak Complicating Central Venous Catheter Insertion

Many of the risks associated with central venous access are well recognized. We report a case of inadvertent lymphatic disruption during the insertion of a tunneled central venous catheter in a patient with raised left and right atrial pressures and severe pulmonary hypertension, which led to significant hemodynamic instability. To our knowledge, this rare complication is previously unreported.

Vascular access

Vascular access is the cornerstone of medical therapy in the pediatric population and presents unique challenges. The vessels are small, often exceedingly so, and gaining access may require considerable patience and skill. Peripheral IVs are difficult to place in children, both because of lack of patient cooperation and because of the very small size of many veins. In addition, repeated venipuncture has been identified as one of the greatest stresses in hospitalized children. In the recent past, all forms of central venous access were the preserve of surgeons and were placed in the operating room under general anesthesia. In recent years, pediatric interventional radiologists have described placing peripherally inserted central catheters (PICCs), subcutaneous venous access ports, hemodialysis catheters, and a variety of temporary and permanent central lines even in the smallest children. This has been achieved safely, reliably, and, by dispensing with general anesthesia and operating room time in most cases, at considerable cost savings to the entire health care system. In addition, new forms of reliable, stable access such as the PICC line have made possible outpatient treatment of a wide variety of conditions, particularly infectious, which previously necessitated hospital admission. This has resulted not only in considerable cost saving for the health care system but also improved quality of life for the patient and their family. In this section, I review the current state of pediatric vascular access with emphasis on those areas where pediatric differs from adult practice.

Radiological placement of chest ports in pediatric oncology patients

A single center's procedural and follow-up results of radiological chest port placement in pediatric oncology patients are presented. Between July 2002 and December 2003, 37 children (20 boys, 17 girls; age range, 4 months to 16 years; mean 6.7 years) underwent chest port placement. All patients received only one port through the internal jugular vein access, and all of the implantations were performed in the interventional radiology suite. Our database and electronic charts were retrospectively reviewed to obtain follow-up data. All chest ports were successfully implanted. The mean catheter life was 223 days (range: 15-450 days), with a total of 8,258 catheter days. Twenty-eight ports are still in use, four patient deceased, one port was prematurely removed because of a late infection, and four patients were lost to follow-up. Infection rate was 2.7% (0.12/1,000 catheter days). Malfunction due to partial catheter thrombosis and fibrin sheath formation was observed in three patients (8.1% or 0.36/1,000 catheter days), and all were relieved with rt-TPA dwell. None of the ports were revised or removed because of blockage, malposition or difficulty accessing the port. The peri-procedural complication rate was 0%. Chest ports in children can be inserted in interventional radiology suites under imaging guidance with high rates of technical success. The rates of infection and complications are comparable to that of surgically placed ports.

Central venous catheter techniques in infants and children

PURPOSE OF REVIEW

The placement of central venous catheters is often necessary to facilitate optimal anaesthetic and perioperative management or for the long-term management of chronic underlying diseases. Insertion may be a challenge in selected patients, and the risk of infection, thrombosis, and other complications may result in significant risk factors.

RECENT FINDINGS

Ultrasound visualization of the cervical veins with Valsalva manoeuvres significantly increases the rate and safety of central venous cannulation, and decreases needle passes in paediatric patients even with experienced operators. Pericardial effusion with tamponade is a more frequent phenomenon than generally realized, and accurate location of the catheter-tip position is essential. The femoral venous approach has proved to be safe even in premature babies. Clear guidelines for infection control and the prevention of intravascular catheter-related infections in children have been established; however, the high incidence of nosocomial catheter-related infections requires effective prevention strategies. The impact of antimicrobial-impregnated central venous catheters on the prevention of bloodstream infections in children is not yet clear. Routine use of prophylactic antibiosis (i.e. vancomycin) to prevent catheter-related infection cannot be recommended. Thrombolytic therapy with recombinant tissue plasminogen activator is safe, efficient, well tolerated and effective for lysis of catheter-induced intravascular and intracardiac thrombi even in neonates. Embolized catheter fragments can be retrieved in neonates and children by non-surgical interventions using standard procedures applied by paediatric cardiologists.

SUMMARY

Despite a variety of new techniques, the major problem of central venous catheterization in neonates and children remains the prevention of catheter-related infection and infection control.